The Evaluation of Canada’s Health Warning Messages: 18 Month Follow-Up Murrray Kaiserman 1, Eva M. Makomaski Illing 1, Donna Dasko 2 1 Tobacco Control.

The Evaluation of Canada’s Health Warning Messages: 18 Month Follow-UpMurrray Kaiserman1, Eva M. Makomaski Illing1, Donna Dasko2

1 Tobacco Control Programme, Health Canada2 Environics Research Group

12th World Conference on Tobacco or Health, August 2003, Helsinki, Finland

Overview

Health Warning Messages in Canada• Purpose• As Health Intervention• Examples

Evaluation of Health Warning Messages• Data Collection• Results

Conclusions

Health Warning Messages in Canada

1994-2000 Post 2000

Two phase introduction:

Dec 23, 2000 & June 26, 2001

Purpose of Health Warning Messages

To inform consumers of the hazards of tobacco use

Secondary Effects:

To encourage cessation

To reduce consumption

To encourage avoidance of the use of tobacco products where they can harm others

Health Warning Messages as a Health Intervention

Frequency of exposure – 74 million hits per day

Target audience – the smoker, including the potential quitter & the potential smoker

Intervention – delivered at time of smoking behaviour

Examples of New Health Warning Messages in Canada

“Canadian warnings are the most vivid in the world and serve as the model for other countries” [The Tobacco Atlas, 2002]

Evaluation of the New Health Warning

Messages –

MAIN OBJECTIVE of SURVEYS –

to provide information to assist in evaluation of the new health warning messages and their effect on public & consumer knowledge & behaviours

Data Collection – ADULTS (Ages 18+)General Population & Smokers Telephone Surveys

Wave 1 (Baseline - prior): November-December 2000

•N=1,502 (1,000 smokers, 502 non-smokers)

Wave 2 (3 months - post): March-April 2001


Wave 3 (6 months - post): July 2001


Wave 4 (12 months - post): November-December 2001




Data Collection – YOUTH (Ages 12-18)Youth Telephone Surveys

Wave 1 (Baseline - prior): December 2000

•N=1,015 (168 smokers, 847 non-smokers) [N=363 potential]

Wave 2 (3 months - post): March-April 2001




Wave 4 (12 months - post): November-December 2001




RESULTS - SMOKING BEHAVIOUR

Smoking Behaviour

30%

17%

36%

28%

13%

36%

31%

15%

33%

25%

17%

36%

28%

13%

32%

0%

5%

10%

15%

20%

25%

30%

35%

40%

Adult Smokers Youth Smokers Potential Smokers (Youth)

Wave 1 (Baseline) Wave 2 (3 Months) Wave 3 (6 Months) Wave 4 (12 Months) Wave 5 (18 Months)

Number of Times Tried to Quit

20%

14%

10%

16%

40%

24%

16%

9%

18%

33%

21%

15%

20%

27%

15%

29%

20%

6%

37%

8%

0%

5%

10%

15%

20%

25%

30%

35%

40%

45%

Once Tw ice Three > Three Not in Past Year

Adults (Wave1) Adults (Wave 5) Youth (Wave 1) Youth (Wave 5)

Q7/Q10 In the past year, how many times have you stopped smoking for at least 24 hours because you were trying to quit smoking? (W5 - Adults: 79%; W5 - Youth: 59%)

Methods Used to Quit

0%

10%

20%

30%

40%

50%

60%

Will Power Patch Zyban Nicotine Gum Gradually Candy Other

Adults (Wave1) Adults (Wave 5) Youth (Wave 1) Youth (Wave 5)

Q8c/Q11c If you were to quit smoking at some point in the future, what ways or methods do you think that you would use?

RESULTS - HEALTH EFFECTS OF SMOKING

Sources of Information About the Health Effects of Smoking

0%

10%

20%

30%

40%

50%

60%

70%

Television CIGARETTEPACKAGES

New spapers Magazines Radio School/University Word of Mouth

Adult Smokers - W1 Adult Smokers - W5 Youth Smokers - W1 Youth Smokers - W5

Youth, Potential - W1 Youth, Potential - W5

Q11/Q14 Thinking generally about information which talks about the health effects of smoking cigarettes, where have you seen or heard any of this kind of information recently? Anywhere else?

Sources of Information About the Health Effects of Smoking – Cigarette Packages

33% 34%

14%

57%

66%

34%

57%

70%

35%

60%62%

33%

58%60%

37%

0%

10%

20%

30%

40%

50%

60%

70%

80%



Q11/Q14 Thinking generally about information which talks about the health effects of smoking cigarettes, where have you seen or heard any of this kind of information recently? Anywhere else?

Health Effects of Smoking – Top of Mind Responses – Gum or Mouth Diseases

1%

4%

5%

2%

9%

5%

4%

6% 6%

4%

7%

6%

4%

8%

7%

0%

1%

2%

3%

4%

5%

6%

7%

8%

9%

10%



Q10/Q13 What specific health effects or diseases, if any, can you think of that can be caused by smoking cigarettes? Are there any others?

Health Effects of Smoking – Aided Responses - Gum or Mouth Diseases – ADULTS

49% 53% 48%54% 50% 53%

29%29%

29%

31%28% 26%

0%

10%

20%

30%

40%

50%

60%

70%

80%

90%

100%

Adult Smokers -W1

Adult Smokers -W5

Male Smokers -W1

Male Smokers -W5

Female Smokers -W1

Female Smokers -W5

% A

gre

e

Strongly agree Somewhat agree

Q12/Q15 I am going to read you a list of human health effects and diseases that may or may not be caused by smoking cigarettes. Based upon what you know or believe, please tell me if you strongly agree, somewhat agree, somewhat disagree, or strongly disagree that smoking can cause each of the following?

Health Effects of Smoking – Aided Responses - Gum or Mouth Diseases – YOUTH

64% 65% 65%73%

66%78%

24% 23% 23%19%

23%

17%

0%

10%

20%

30%

40%

50%

60%

70%

80%

90%

100%

Youth Smokers -W1

Youth Smokers -W5

Male Youth - W1 Male Youth - W5 Female Youth -W1

Female Youth -W5

% A

gre

ee



Health Effects of Smoking – Top of Mind Responses – Impotence

3%

9%

4%

2%

4%

1%

2%

4%

2%2%

6%

1%

0%

1%

2%

3%

4%

5%

6%

7%

8%

9%

10%



Q10/Q13 What specific health effects or diseases, if any, can you think of that can be caused by smoking cigarettes? Are there any others?

Health Effects of Smoking – Aided Responses - Impotence – ADULTS

14%19% 16% 18%

13%20%

23%

29%

26%

32%

19%

24%

0%

10%

20%

30%

40%

50%

60%

70%

Adult Smokers -W1

Adult Smokers -W5

Male Smokers -W1

Male Smokers -W5

Female Smokers -W1

Female Smokers -W5

% A

gre

e


Q12/Q15 I am going to read you a list of human health effects and diseases that may or may not be caused y smoking cigarettes. Based upon what you know or believe, please tell me if you strongly agree, somewhat agree, somewhat disagree, or strongly disagree that smoking can cause each of the following?

Health Effects of Smoking – Aided Responses - Impotence – YOUTH

18%

38%

14%

28%

15%

27%

27%

25%

29%

31%

28%

29%

0%

10%

20%

30%

40%

50%

60%

70%

Youth Smokers -W1

Youth Smokers -W5

Male Youth - W1 Male Youth - W5 Female Youth -W1

Female Youth -W5

% A

gre

e



Specific Health Effects Caused by Smoking

0%

10%

20%

30%

40%

50%

60%

70%

80%

90%

100%

LUNGCANCER

Emphysema GUM/MOUTHDISEASE

Blood clots IMPOTENCE Infertility Acne

% Agree

Adult Smokers-W1 Adult Smokers-W5 Youth-W1 Youth-W5


Specific Health Effects Caused by Second-Hand Smoke

0%

10%

20%

30%

40%

50%

60%

70%

80%

90%

100%

LUNG CANCERIN NON-

SMOKERS

Chest infectionsin children

Strokes in non-smoking adults

Sudden InfantDeath Syndrome

Multiple Sclerosisin non-smoking

adults

Arthritis in non-smoking adults

% Agree

Adult Smokers-W1 Adult Smokers-W5 Youth-W1 Youth-W5

Q13/Q16 Here is a list of human health effects and diseases that may or may not be caused by breathing in second-hand smoke from cigarettes. Based on what you know or believe, please tell me if you strongly agree, somewhat agree, somewhat disagree, or strongly disagree that smoking can cause each of the following?

RESULTS – DEATHS FROM TOBACCO USE

Smoking Attributable Mortality – 45,000 Deaths

16%15%

18%19%

24% 24%23%

28%

21%

26%28%

24%

27%

36%

27%

0%

5%

10%

15%

20%

25%

30%

35%

40%

Adults Smokers Youth Smokers Potential Smokers (Youth)


Q15/Q18 Which of the following do you think is the closest approximation of the number of Canadians who die each year as a result of tobacco use? Is it closest to ….?

RESULTS – HEALTH WARNING MESSAGES

Looking at the Health Warning Messages

0%

5%

10%

15%

20%

25%

30%

35%

40%

45%

50%

Several times a day About once a day Once every two orthree days

About once a week Less than once aweek

Never

Adult Smokers - W1 Adult Smokers - W5 Youth Smokers - W1 Youth Smokers - W5Youth, Potential - W1 Youth, Potential - W5

Q21a/Q24a About how often do you find yourself looking at, or reading health warning messageson cigarette packages? Would it be …..?

Recall of Specific Health Warning Messages on Cigarette Packages – Adult Smokers

19%

16% 16%17%

9%

18%

16%15%

17%

8%

17%16%

20%

22%

9%

23%

18%

24%

18%

11%

0%

5%

10%

15%

20%

25%

30%

Harmful duringpregnancies

Causes lungcancer

IMPOTENCE Harmful toothers/children

MOUTH/GUMDISEASE

Wave 2 (3 Months) Wave 3 (6 Months) Wave 4 (12 Months) Wave 5 (18 Months)

Q23 Without looking at a cigarette package, when it comes to the new health warning messages on cigarette packages, what specific health warning messages can you remember? Are there any others?

Recall of Specific Health Warning Messages on Cigarette Packages – Youth Smokers

15%

20%

29%

27%

11%

20%

22% 22%

26%

8%

14%

21%

32% 32%

7%

17%18%

30%

27%

8%

0%

5%

10%

15%

20%

25%

30%

35%

Harmful duringpregnancies

Causes lungcancer

IMPOTENCE Harmful toothers/children

MOUTH/GUMDISEASE


Q26 Without looking at a cigarette package, when it comes to the new health warning messages on cigarette packages, what specific health warning messages can you remember? Are there any others?

Impact of the Health Warning Messages - Informing

54%

74%

64%

79%

69%

84%

68%

83%

0%

10%

20%

30%

40%

50%

60%

70%

80%

90%

Adult Smokers Youth Smokers

% E

ffec

tive


Q27/Q30 Thinking about the new health warning messages you have seen on cigarette packages, have these messages been very effective, somewhat effective, not very effective or not at all effective in each of the following ways ….?

Impact of the Health Warning Messages – Getting you to try quitting

36%

50%

38%

51%

43%

55%

45% 44%

0%

10%

20%

30%

40%

50%

60%

Adult Smokers Youth Smokers

% E

ffec

tive


Q27/Q30 Thinking about the new health warning messages you have seen on cigarette packages, have these messages been very effective, somewhat effective, not very effective or not at all effective in each of the following ways ….?

Assessment of the Health Warning Messages - Accurate

78%

88%93%

77%

85% 87%82%

90%94%

80% 82%

95%

0%

10%

20%

30%

40%

50%

60%

70%

80%

90%

100%


% A

gre

e


Q25/Q28 Thinking generally about new health warning messages on cigarette packages in Canada, do you strongly agree, somewhat agree, somewhat disagree or strongly disagree with each of the following statements….

Assessment of the Health Warning Messages – Provide Important Information

78%

95% 94%

78%

90%93%

81%

96% 96%

80%

85%

94%

0%

10%

20%

30%

40%

50%

60%

70%

80%

90%

100%


% A

gre

e


Q25/Q28 Thinking generally about new health warning messages on cigarette packages in Canada, do you strongly agree, somewhat agree, somewhat disagree or strongly disagree with each of the following statements…

RESULTS – TOXIC SUBSTANCES

Toxic Substances in Cigarettes

0%

10%

20%

30%

40%

50%

60%

Nicotine Tar Carbon monoxide Benzene Hydrogen cyanide Formaldehyde

Adult Smokers-W1 Adult Smokers-W5 Youth Smokers-W1 Youth Smokers-W5Youth,Potential-W1 Youth,Potential-W5

Q32/Q35 Without looking at anything, what if any, chemicals or toxic substances can you name that are in cigarettes or cigarette smoke? Are there any others?

Conclusions

Smokers’ awareness of the health outcomes of smoking remains high

Smokers continue to strongly support and approve the new health warning messages

Smokers continue to read the messages

Conclusions After 18 months, messages continue to be noticed

• with a trend away from general mention of pictures and towards reference to specific images (e.g. pictures/diseases of mouth/teeth), design elements or messages

After 18 months, smokers’ learning is continuing to show definite signs of growth

After 18 months, health warning messages are not demonstrating any indication of wear out

The Evaluation of Canada’s Health Warning Messages: 18 Month Follow-Up Murrray Kaiserman 1, Eva M. Makomaski Illing 1, Donna Dasko 2 1 Tobacco Control.

Documents

nonsmokers n

potential slide

health canada

nonsmokers wave

potential wave

finland slide

months post

youth telephone surveys